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MONING SYSTEM CERTIFI*TION ForWe By All Jurisdictions Within the State of Cali is Authority Cited: Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A se crate certification for each monitoring system control panel by the technician who performs the work. A copy of this form must be pr /operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 d y s`t da A. General Information Facility Name ARP MINI MART Site Address: 25775 Pattersn Pass Rd. Facility Contact Person: Neilsh Patel Make/Model of Monitoring System: veeder root TLS -350 B. Inventory of Equipment Tested/Certified Check the aonrooriate boxes to indicate specific couinment insnerted/serviced: City: A ? R 3. 5 20 10 IVIRUNh1hNT hiEALTH PERMiT/SU4V Contact Phone No.: (209) 830-7777 Date of Testing/Servicing: 3/29/2010 Tank ID: T-1 87 Slave Tank ID: T-2 87 Master ® In -Tank Gauging Probe. Model: 107 ® In -Tank Gauging Probe. Model: 107 ® Annular Space or Vault Sensor. Model: 407 ® Annular Space or Vault Sensor. Model: 407 ® Piping Sump / Trench Sensor(s), Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: 8484 ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E- on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2 ). Tank ID: T-3 87 Syphon Tank 1D: T-4 Premium ® In -Tank Gauging Probe. Model: 107 I ® In -Tank Gauging Probe. Model: 107 ® Annular Space or Vault Sensor. Model: 407 ® Annular Space or Vault Sensor. Model: 407 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: 8484 ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specif}- equipment tN pe and model in Section E on Pave 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 112 Dispenser ID: 314 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). ii we iacuuy coniums more tanxs or dispensers. copy this torm. Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): ® System set-up ® Alarm history report Technician Name (print): Robert Barnhart Certification No.: B36969 Signature: � �n_.hCL+t;aG•-•�-� License. No.: 883706 Testing Company Name: Reliable Petroleum Service Inc. Phone No.: (209) 645-8586 Testing Company Address: 521 Branding Iron Street, Oakdale CA 95361 Date of Testing/Servicing: 3/29/2010 Page 1 of 4 UN -036 —1/4 www.unidocs.org Rev. 01/17/08